A couple of years ago I found myself in need of a dissertation topic for an MSc in Public Health – ‘make sure it’s something you are interested in’ was the advice. Simple I thought, I just need to weave football and beer into a research project! All joking aside though, I have become interested in the relationship between the two over the years.

As a public health professional and former A&E nurse, I am well aware of the potential harms of excessive alcohol consumption. Also, as a fan who both attends matches and watches on TV, I have become increasingly aware at how visible this relationship has become. Of course, football and beer have long been associated, ever since Victorian landlords would set up teams, use the land out back for a pitch and, in the amateur days, employ the team as barmen in lieu of pay.

But at the risk of sounding like my dad, when I ‘was a lad’, you either went to the match, where as a young working class man it was normal to have a pint with the lads, or you waited for Saturday night’s Match of the Day for your football fix. The pubs were open sporadically, had no TVs, and the football was rarely broadcast anyway.

Fast forward a few years and we have football on satellite TV almost every night of the week and all day at weekends, most top flight football clubs sponsored at some level by an alcohol brand, marketing of alcohol, beer in particular, is rife and the norm appears to be drink beer and watch football with the lads in the pub. Opportunities to do both are far more common than when ‘I was a lad’, and not just within pubs, but within living rooms, where the cheaper alcohol deals of the supermarkets are very popular. As a dad myself I was disturbed by these developments, but hadn’t been able to quantify them.

I decided my dissertation would try to measure the amount of alcohol marketing that football TV viewers were exposed to. With the help of Jean Adams at Newcastle University, I planned the research. I chose six live broadcasts representing over 18 hours of footage, developed coding frameworks and watched 40 hours plus of coding footage to consider all the verbal and visual references.

The results shocked me:

• Over 2,000 visual images, 111 per hour on average, or around 2 per minute.

The issue of traditional advertising commercials is interesting because the ‘voluntary’ codes of practice in place to regulate how alcohol is portrayed (should not appeal to youth, should not suggest social success, etc.) are most relevant to this type of advertising. Given that we know that quantity of alcohol marketing is more important than content, then the apparently unchecked stream of visual references in this research may be even more important, and we could argue that the current controls are completely inadequate because they are focused on content, rather than quantity.

I can’t help but feel that we have taken our eye off the ball – the globalisation of sports such as premier league football as a product, the satellite age, the endless thirst for profit and market share within corporations, the ‘self’ regulation that fails to control the exposure reported above, the relaxed licensing laws in this country, and the increase in type, availability, and affordability of alcohol. All of these things create a perfect storm in which alcohol and sporting idols become normalised as one and the same, and the brand becomes a member of the team. It feels as though the relationship between sport and alcohol has evolved towards its perfect and logical form.

I am disturbed to be one of a generation of football fans that has been manipulated in this way and that my children are also targets. And meanwhile, the alcohol industry has a seat at the policy making table through the Public Health Responsibility Deal. So we must ask the question: are we sleepwalking into a situation where drinking alcohol is so closely associated with the sporting heroes that children see on TV, that they are being actively normalised to become drinkers? No one seems to question this, but it is time someone did, and through public health advocacy it may just be up to us.

What is the best way to advocate and improve public health policy? Quietly and diplomatically, or through loud and public protest? Or is there room for both approaches?

These are some of the questions that are part of the discussion that led to the Faculty of Public Health’s (FPH) recent decision to withdraw from the government’s Responsibility Deals, a group drawn from industry, local authorities and the public health community.

The aim of the responsibility deal was to provide a quicker means of improving public health policy than bringing new legislation before parliament. The logic was that a ‘carrot not stick’ approach would lead to faster progress than forcing companies to meet new legal requirements. Participating organisations signed up to pledges on public health issues such as physical activity, taking a billion units of alcohol out of circulation or reducing calories in food.

FPH had representatives on the alcohol, food, physical activity and health at work networks until July 2013. We owe a debt of thanks to those FPH representatives who gave up their time to challenge decision-making and question the logic of the direction public health policy was taking. We can be sure that their input has helped mitigate some of the worst excesses of a commercial need to put the value of shares ahead of public health.

FPH’s decision to join the responsibility deal was controversial and much debated throughout the past two years. There are many people within the public health community who disagreed with our participation. Others felt it was better to be at the table, than to leave the debate unchallenged by public health expertise.

Given how public health policy has developed in recent years, the available options for effective advocacy have sometimes seemed like the moment in the film Argo when CIA officer Jack O’ Donnell has to admit that the ludicrous-sounding plan to rescue American hostages in Tehran, by pretending they are the crew of a sci-fi fantasy movie, is the ‘best bad idea’ he has.

Unlike the fictional and public world of a Hollywood film, much of public health advocacy goes on in a less public fashion. It has become clear that government public health policy has fallen victim to a concerted and shameful campaign of lobbying by sections of the tobacco and drinks industry who are putting profits before health and public safety.

The balance of gains and losses of participating in the responsibility deals shifted recently when the Government made it clear that a minimum unit price for alcohol and standardised packs for cigarettes would not be introduced.

In light of this, we withdrew from all of the Responsibility Deal groups. Using legislation to bring in measures like minimum unit pricing would have been quicker than a ‘softly softly’ approach. There is also no way of knowing if the responsibility deals have been truly effective because it is unlikely the key pledges will be evaluated.

For example, there is no case for saying that the Billion Unit Pledge for alcohol is a success because any gains from people drinking lower alcohol beer have been cancelled out by the increase in people drinking wine and spirits. On these two measures alone, the Responsibility Deals have not achieved their original purpose.

FPH has worked with governments of all political persuasions since it was first founded over 40 years ago. We want to continue to work with Government to improve people’s health. We know that the best way to improve everyone’s health is by working in partnership and we remain committed to doing so. However, we, like other NGOs with limited resources for the important work we do, need to make sure we use our influence and expertise in the most effective way possible. We look forward to continuing our advocacy work and will keep you updated on how it progresses.

Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners. Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost. Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are. Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base. But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery. This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

Health Secretary Andrew Lansley wants to encourage people to eat healthily, drink sensibly, stop smoking and get more active without lecturing or hectoring them. People don’t like being told what to do or not do – least of all by the Government – so Lansley says we should provide them with information and incentives and let them choose for themselves – nudging rather than nannying. Hence the Great Change4Life Swapathon with its supermarket discount vouchers for healthy options. Lots of carrots, no sticks.

There’s also much nudging behind Lansley’s Responsibility Deal with the food, drink and fitness industries. Double nudging – Lansley nudging them to nudge the public. Industry will “pledge” to provide information and incentives encouraging healthier choices.

So where’s the fudge? In return for industry cooperation (and cash) Lansley has said he’ll go easy on mandatory regulations around such things as marketing, labelling, availability and pricing. To be fair, he doesn’t rule these threats out completely. He talks about the Nuffield Ladder of Interventions, with the least intrusive (information, education and incentives) at the bottom and the most intrusive (regulation and legislation) at the top. But he’s made it clear he doesn’t want to climb that ladder unless he absolutely has to. It wouldn’t fit his political philosophy.

So there’s a big fudge around how he’ll monitor adherence to voluntary approaches, assess progress and judge when to bring in mandatory controls. The food and drink industries are notoriously slippery, evasive and foot-dragging – just look at labelling and marketing. Meanwhile the health lobby is going along with the Responsibility Deal in the hope that things might be different this time – well aware they risk being be-smudged as part of the fudge.

I’d like to see a solid pledge by the Government to regulate or legislate if voluntary approaches fail and to be crystal clear about how and when such judgements will be made. Without an explicit commitment to use force if necessary, the deal will be seen as no more than a charade letting Big Business off the hook.

As expected, all three major political parties have this week made strong references to public, or, as they most commonly term it, preventive health in their election manifestos.

Ahead of the General Election on 6 May, the Conservative party have, at least superficially, made the most explicit commitment, with their pledge to re-title the signs outside Richmond House “The Department for Public Health”. As we already learnt in their draft manifesto back in January, they intend to rechannel public health funding to the most deprived areas, offering a financial “premium” to target health inequalities. Confusion reigns as to how this might be implemented, and the manifesto in general is long on the whats, but short on the hows, but the proposals are certainly attractively packaged, at least for the floating voter.

The present incumbents have of course to defend their record, as well as identify areas where they could do better. Labour face the accusation, made in the Tory manifesto, that inequality has increased on their watch. An interesting spin on this was printed by the Institute of Fiscal Studies, but Labour’s manifesto is relatively weak on how they would further level the playing field. The author of the Labour manifesto, Ed Miliband had previously trailed the idea of universal free school meals, something that FPH had also touted in our manifesto. This pledge is somewhat toned down in the manifesto proper, instead promising to “trial free school meals for all primary school children in pilot areas across the country … [to] thoroughly test the case for universal free school meals, with the results available by autumn 2011”.

Most commentators agree that the NHS has improved under Labour, (at least enough for the Conservative party to want to claim themselves to be the rightful heirs of Bevan’s legacy) but their commitment to the preventive agenda is vague at best. Citing their current (and, in some quarters, heavily criticised) Change4Life social marketing campaign, and the smoking ban as evidence for the defence is fine, but where are the plans to make a healthy “future fair for all”?

The Liberal Democrats, with their eminently sensible and intelligent spokesperson Norman Lamb, possibly have the most tangible pledges for the nation’s health. The cynic might of course argue that they can afford to make such idealistic and resource-intensive promises, unlikely as they are to assume the reigns of power. Nonetheless, persuading a party to nail its colours to the mast of minimum alcohol pricing is no mean feat, particularly when their colleagues north of the border are more reticent to declare themselves. The Lib Dems also follow the Conservative’s lead in linking financial incentives to addressing inequalities, “linking payments to health boards (as they would rename Primary Care Trusts) and General Practitioners more directly to prevention measures”. Lamb has talked previously about what essentially amounts to a beefed-up Quality and Outcomes Framework (QOF), paying GPs for achievements rather than measurements.

A curate’s egg for public health then from all the parties; whichever the colour of the incoming government, they still have work to do to clarify how they will improve the nation’s health, particularly in financially straitened times.

Very long faces in the West Country this week. Despite much pressure from the health lobby, Alistair Darling has chosen to ignore calls for minimum pricing of alcohol, and instead has imposed a hefty tax hike on cider. In Wednesday’s Budget statement, the Chancellor announced a duty increase of 10% above inflation for cider compared with 2% above inflation for other alcoholic drinks across the board.

In recent years cider has enjoyed something of a tax holiday, making it a firm favourite among young people with little money and big thirsts. Cider has been a cheap way to binge-drink, and the budget hike is intended to bring it back into line on duty and price.

But are above-inflation tax hikes the best fiscal strategy for tackling alcohol misuse – especially binge-drinking by young people? Why the aversion to minimum pricing as an additional measure?

The problem with hikes in duty is that they can be easily absorbed by the supermarkets, which continue to offer cheap drink as loss-leaders to draw people into their stores. Many deeply discounted drinks are currently being offered at less than the cost of VAT, and these tend to be the very lines, such as strong ciders, lagers and alcopops, that are especially popular with young people.

Minimum pricing, on the other hand, has to be passed on to the customer. By fixing a minimum price per unit of alcohol sold – in other words, banning ultra-cheap offers on booze – the government can ensure that no drink can be bought at less than, say, 50p per unit, the figure recommended by England’s Chief Medical Officer as an ‘immediate priority’ over a year ago. This would mean no less than £5.50 for a 2-litre bottle of normal-strength cider (compared with many current offers under £2), £6 for the average six-pack of lager and £4.50 for a typical bottle of wine – more for higher strength versions.

The impact on health could be considerable. Consumption is closely linked to price, and a team at Sheffield University have calculated that, with a minimum of 50p per unit, every year the UK could see: 3,393 fewer deaths, 97,900 fewer hospital admissions, 45,800 fewer crimes, 296,900 fewer sick days, and a total benefit of over £1 billion. The deterrent effect and health benefits would be greatest for the heavier drinkers, especially those with the least disposable income.

With an election in the offing, the tax versus minimum pricing issue has split the parties. The Lib Dems are likely to be for it, Labour against (after Gordon Brown’s flat refusal to accept the CMO’s recommendation last year) and the Tories somewhere in between (on selected types of drink favoured by young people). In Scotland the parties line up differently – perhaps distorted by the distilleries – and the SNP-led efforts to drive through legislation are having a rough ride.

But, after the election, there’ll be all to play for. My guess is that common sense will break out and minimum pricing will soon be on the statute book as a useful adjunct to increases in duty. It won’t be either/or, but both/and. There’s still a chance that, just as it did with smoke-free legislation, Scotland could lead the way.

Or perhaps a fresh lot of Westminster MPs will see the light, and a ban on deep discounting of booze could be one of the early benefits of a hung parliament.

Good news for the nation’s health – but maybe less so for the apple-growers and cider-makers of the West Country.

Sir Liam Donaldson, the Chief Medical Officer has published his Annual Report 2009 this week. In the report the CMO highlights the key areas of public health requiring action and looks at progress made since previous annual reports. One issue that he reflects on is the damage caused by “passive” drinking and the recommendation he made for a minimum price for alcohol in his last Annual Report.

FPH President Professor Alan Maryon-Davis commented:

We’re strongly behind Sir Liam on this issue. The government should never have bottled out with minimum pricing. It makes total sense to ban ultra-cheap booze. We call on this government and future ones to reconsider all the evidence that is available.

The Alcohol Health Alliance UK brings together the Royal College of Physicians, the Royal College of Surgeons, the Academy of Medical Royal Colleges, the Faculty of Public Health and 20 other such organisations. To see such a group of medical bodies speaking together with one voice is very powerful. They speak in particular of the passive harms of drinking. They, too, call for a minimum price per unit.

Other professionals have echoed this call. The Faculty of Public Health represents 3,000 public health specialists from the United Kingdom and elsewhere. The Royal Society for Public Health has 6,000 members from health-related professions. In January 2010, these two institutions joined forces to publish a public health manifesto. It listed 12 actions that government could, and should, take to tackle a range of public health concerns. The first action on the list was a minimum price per unit of alcohol. (p.16)

The major challenges the Annual Report discusses this year include climate change and health, the benefits of physical activity on health and risk of cold weather on health.

There is plenty of evidence about alcohol minimum pricing being the best public health intervention to problem drinking, for instance an independent review by the School of Health and Related Research at Sheffield University.

Disclaimer

The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.